Going strong in So Africa … Dr. Kauffman faces week #2

The second week has begun.  Today was an eventful day.  I arrived at the Jubilee Wellness clinic and began seeing patients with Dr. Tom Rambau.  Dr. Vusimuzi Baloy did not show because he was in an auto accident over the weekend but not seriously hurt.  Dr. Raymond Mabuse was there, however, and I must say I think he is probably one of the better physicians.  You may remember he is the liaison between the Wellness Clinic and the hospital.

Mid-morning I went to the hospital to make rounds with the ward physicians.  A new problem patient was a 69 year old gentleman who was with very low CD4 count, was unresponsive and had hypertension and diabetes.  He had a very foul-smelling, gangrenous right lower extremity from entire foot to mid-calf.  Surgery had been consulted but they refused to amputate because of his very poor medical condition.   I agreed that surgery would probably be the cause of his death, but then so is doing nothing.  I advised Dr. Isila to just make him comfortable.  The gentleman with the CD4 count of 1 had passed away during the weekend.  That was the male ward, ward #3.

The female ward was just as eventful if not more so.  One lady named Rachel, that I had seen last Thursday and Friday with severe hepatic disease looked much worse today.  When I saw her on Thursday, we found her liver to be very enlarged and tender.  Dr. Kinkel performed an ultrasound but found no obstructive lesions.  There was quite severe fatty infiltration of the liver parenchyma and it was very enlarged filling most of the right side of the abdomen and extending into the left upper quadrant.   Her liver function tests were elevated with the bilirubin exceedingly high.  Dr Kinkel started her on treatment for tuberculosis with ethambutol, streptomycin and ciprofloxacin.  Her quick test for HIV was negative.  On Friday her condition was about the same so I asked Dr. Stanley Matlala to get an Elisa test for HIV.  Today I found out the Elisa test was negative and she had a CD4 count of 666.  When I came into the ward, she was moaning constantly and barely able to respond.  She was holding her headas if in pain and when tested for nuchal rigidity, her neck was stiff.  We performed a lumbar puncture with quite a bit of difficulty because she was not very compliant.  The cerebrospinal fluid (CSF) was yellowish but not turbid.  Dr. Matlala requested all the usual tests on the CSF he had obtained.  I asked him to repeat all of her labs: CBC with differential, LFT’s tests and also for cytomegalovirus (CMV) titers.  She may not make it through the night.  That was the female ward, ward #3.

Then it was back to the Wellness clinic (the name does not lend itself to its patients).  Dr. Tom was seeing a lady in a wheelchair who was diagnosed with HIV/AIDS over a month ago.  She had been to two counseling sessions and was here for the third.  She looked very sick with sunken eyes, and difficulty breathing.  Dr. Tom had ordered a chest x-ray (CXR) which showed a massive heart.  He said she had a CXR two weeks ago which revealed a normal cardiac shadow but it was not available today. She still had not been started on HAART.  Dr. Tom said she wasn’t ready psychologically to get started.  That she would take the medicine home and “default”.  He made a presumptive diagnosis of TB pericarditis and was in the process of starting her on the TB protocol and send her home.  He did all this without laying a hand on the poor lady. I asked if I could check her and the chart out.  I knew if she went home she would not live to see the clinic again.  Her heart sounds were rapid but I could not hear any rubs, murmurs or gallops.  Her abdomen was distended and I could feel ascites.  Her LDH was over 1400 but the ALT and AST were normal.  I said I thought she should be admitted to the hospital, started on HAART and observed.  She could well have TB pericarditis or cardiomyopathy or even possibly a PCP pneumonia with a negative CXR.  We know that from 20 to 50% of patients can have PCP pneumonia with a negative CXR.  Dr Mabuse came in and examined the patient. He too, thought she should be admitted.  So she was and HAART was started.  All total, the clinic saw around 130 today.  That was the Wellness Clinic!

Dr. Kauffman settles into South Africa

My first week has been splendid!  Drs. Anton and Tania Stoltz are wonderful hosts.  Tania is a splendid cook and I doubt I will lose any weight while here these six weeks.  They have a three and a half year old son named Armand who goes with his mother and her dog to her office each day!  The Guest House is set on a steep hill overlooking Pretoria.  Rose, the maid comes in every day and gives me clean, fresh sheets and towels.  She does the laundry and irons my clothes too!  The guesthouse is well appointed and could be mistaken for a fine hotel.  I have my second car, just got it today, a Nissan with manual transmission…a step up from the Opal I had for the first 4 1/2 days.  The trip to Hammanskraal takes me approximately 45 minutes going at speed limit which is 120 k/h.  Hammanskraal is one of the homelands where thousands of people live in tiny houses stacked on each other.  There are such houses stretching as far as the eye can see in all directions.  After adjusting to jet lag, today is the first day that I can truly say I feel recovered.

The first day at Hammanskraal’s Jubilee Hospital we saw approximately 170 patients in the HIV Wellness Clinic.  Jubilee serves a very large area, not just Hammanskraal, but the entire Gauteng Province and is a secondary referral hospital from the rural clinics.  I had two doctors in the wellness clinic, Dr. Michael Thomas Rambau (Tom), and Dr. Vusimuzi Baloy (Vusi).  Tom is 67 years old and is quite the talker.  Vusi is much younger, only 33 years old.  Both of these gentlemen seem quite eager to learn.  I was quite impressed with their competence and willingness to see the huge number of people that flooded the clinic.  There really was not enough time for the physicians to do proper examinations and history review.  This will definitely lead to the practice of poor medicine.  I am empathetic and understand the need for brevity because of the numbers of people they must see.  Nevertheless, this is not HIV medicine at its best.

The other doctor, Dr.Raymond Mabuse, the liaison between hospital ward physicians and the wellness clinic, I only met briefly on the first full day, Tuesday 07/07/09.  I only saw him again briefly on Wednesday and not at all on Thursday or today, Friday.  I do not know the details of why I haven’t seen him.

I made hospital ward rounds with Dr. Fritz Kinkel from FPD and the ward doctors:

Dr. Morekane Ramasod (lady) and Dr. Stanley Matlala in Ward 2, the female HIV ward.  Both of these doctors are doing their four month public service stints.

Dr. Boikhutso (lady) and Dr. Isila in Ward 3, the male ward.  Dr. Boikhutso is also doing her four month public service.  Dr Isila is a government doctor who is chief of the HIV medicine wards.

Several problem patients were identified:

One was a female patient admitted the night before with fulminant PCP pneumonia.  The ward doctors had started her on appropriatly on an antibiotic but we suggested that she also was started on high dose steroids.  She was alert and talking to us albeit short of breath.  When I arrived this morning to make rounds, her bed was empty…she had expired during the night.  I asked if thesteroids had been given.  The answer was a nonchalant “I don’t know”!

The other patient was a man I saw on Thursday who was very confused and close to being obtunded.  He had been there several days and basically had not been cared for.  Nobody knew where he had come from, there were no relatives to be called.  The poor man was curled up in his bed, mouth-breathing had formed thick scum on his teeth…nobody bothered to give mouth care.  The ward doctors had ordered HIV testing which was positive and CD4 count was only 1 (one)!!!  He responded to me calling his name but he could hardly do more than that.  I instructed the staff to start HAART immediately or the man would surely die.  Since only the HIV Wellness Clinic physicians can prescribe HAART medications, the chart was taken to the outpatient clinic.  Dr. Tom Rambau looked at the chart but did not bother to go see the patient.  He merely wrote in the chart that the patient must have counseling  and have liver function tests first before HAART would be prescribed!  Today I went  to make rounds in the wards and found that HAART had still not been started.  Needless to say, in short order the man had HAART!  Dr. Tom’s argument was that the SA Guidelines had to be followed.  Counseling! To a basically unresponsive patient?!  Liver function tests!  The man was going to die without the medications, it is his only hope.

Today, Friday July 10,2009, started well.  I had been asked to make a lecture presentation every Friday to the entire hospital physician staff since HIV affects every aspect of medicine here in South Africa.  So all the department heads and most of the HIV doctors gathered in the main Boardroom at 8:45.  My lecture was on Basic HIV Virology made simple.  It went very well with questions being asked.  In the end they gave me a round of applause.  One physician said he had always been confused what “Reverse Transcriptase”, “Integrase”, “DNAase” meant.  After my lecture he told me it all crystallized for him and now he understood.  Quite gratifying.

That was my first week in South Africa!  I call it a great start.

Dr. Kauffman shares his talents and gifts across the globe…

… Dr. Kauffman headed out to South Africa mentoring local physicians on how to diagnose and treat HIV/Aids.  Along with  two local South African physicians, they arrived at the Jubilee Hospital to face approximately 170 patients with this dreadful disease.  Dr. Kauffman’s saddest case was a nine year old child who was born with HIV.   Dr. Kauffman diagnosed this innocent boy with double pneumonia and probably a case of PCP and TB.  Dr. Kauffman’s most touching moment came when a man came into the examining room barely able to walk, very gaunt and emaciated.  When the patient was told that Dr. Kauffman had come from America to help, the patient’s face broke with a smile and told Dr. Kauffman, “You are very welcome!”

Honduras & Belize 2008

Along with 17 other Saint Markers, we left Atlanta on board a Delta flight and had a rather bumpy ride to Honduras.  We arrived at the San Pedro Sula International Airport in good shape and after clearing customs and immigration, we piled into two vans with our luggage heaped onto a pickup truck for the three hour ride to La Ceiba.

Medical Mission & Nicole Rodriguez

The medical mission trip to the small village of El Pino, Honduras and the Belizean jungle village of Dolores is now a fond memory. Along with twenty five other members of the Saint Mark United Methodist Church, I left for Honduras on July 07, 2007. We consisted of a medical team with two physicians, a nurse and a pharmacist, a dental team with a portable dental chair, two construction teams and an educational team.

ICEHA

It takes only 6 months of clinical mentoring and $24,000 in cash funding to give 50 local healthcare workers in a developing country the competence and confidence to understand the ins and outs of HIV/AIDS and comfortably treat AIDS patients in a clinically justified manner. Click here for more info.

Flu Shots

Autumn is fast approaching! It is time to begin thinking about flu shots

The outbreak of the influenza epidemic occurs worldwide …usually in the winter months. Dr. Kauffman recommends that everyone is vaccinated.

Cambodia

As a member of the Southeastern Board for the American Academy of HIV Medicine, I received a request for volunteers to teach local physicians how to properly treat HIV and AIDS in a developing country. Deep in my heart I immediately knew this was a call from God for me to GO. This would be a three month commitment. I was very fortunate to find a physician to keep my clinic open during my absence.